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Miyanishi K, Hotta-Hirashima N, Miyoshi C, Hayakawa S, Kakizaki M, Kanno S, Ikkyu A, Funato H, Yanagisawa M. Microglia modulate sleep/wakefulness under baseline conditions and under acute social defeat stress in adult mice. Neurosci Res 2024; 202:8-19. [PMID: 38029860 DOI: 10.1016/j.neures.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Abstract
Although sleep is tightly regulated by multiple neuronal circuits in the brain, nonneuronal cells such as glial cells have been increasingly recognized as crucial sleep regulators. Recent studies have shown that microglia may act to maintain wakefulness. Here, we investigated the possible involvement of microglia in the regulation of sleep quantity and quality under baseline and stress conditions through electroencephalography (EEG)/electromyography (EMG) recordings, and by employing pharmacological methods to eliminate microglial cells in the adult mouse brain. We found that severe microglial depletion induced by the colony-stimulating factor 1 receptor (CSF1R) antagonist PLX5622 (PLX) reversibly decreased the total wake time and the wake episode duration and increased the EEG slow-wave power during wakefulness under baseline conditions. To examine the role of microglia in sleep/wake regulation under mental stress, we used the acute social defeat stress (ASDS) paradigm, an ethological model for psychosocial stress. Sleep analysis under ASDS revealed that microglial depletion exacerbated the stress-induced decrease in the total wake time and increase in anxiety-like behaviors in the open field test. These results demonstrate that microglia actively modulate sleep quantity and architecture under both baseline and stress conditions. Our findings suggest that microglia may potentially provide resilience against acute psychosocial stress by regulating restorative sleep.
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Affiliation(s)
- Kazuya Miyanishi
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Noriko Hotta-Hirashima
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Chika Miyoshi
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Satsuki Hayakawa
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Miyo Kakizaki
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Satomi Kanno
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Aya Ikkyu
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Hiromasa Funato
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan; Department of Anatomy, Toho University Graduate School of Medicine, Tokyo 143-8540, Japan
| | - Masashi Yanagisawa
- International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8575, Japan; Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; Life Science Center for Survival Dynamics, Tsukuba Advanced Research Alliance, University of Tsukuba, Tsukuba 305-8577, Japan.
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Sun R, Tang MY, Yang D, Zhang YY, Xu YH, Qiao Y, Yu B, Cao SX, Wang H, Huang HQ, Zhang H, Li XM, Lian H. C3aR in the medial prefrontal cortex modulates the susceptibility to LPS-induced depressive-like behaviors through glutamatergic neuronal excitability. Prog Neurobiol 2024; 236:102614. [PMID: 38641040 DOI: 10.1016/j.pneurobio.2024.102614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/18/2024] [Accepted: 04/16/2024] [Indexed: 04/21/2024]
Abstract
Complement activation and prefrontal cortical dysfunction both contribute to the pathogenesis of major depressive disorder (MDD), but their interplay in MDD is unclear. We here studied the role of complement C3a receptor (C3aR) in the medial prefrontal cortex (mPFC) and its influence on depressive-like behaviors induced by systematic lipopolysaccharides (LPS) administration. C3aR knockout (KO) or intra-mPFC C3aR antagonism confers resilience, whereas C3aR expression in mPFC neurons makes KO mice susceptible to LPS-induced depressive-like behaviors. Importantly, the excitation and inhibition of mPFC neurons have opposing effects on depressive-like behaviors, aligning with increased and decreased excitability by C3aR deletion and activation in cortical neurons. In particular, inhibiting mPFC glutamatergic (mPFCGlu) neurons, the main neuronal subpopulation expresses C3aR, induces depressive-like behaviors in saline-treated WT and KO mice, but not in LPS-treated KO mice. Compared to hypoexcitable mPFCGlu neurons in LPS-treated WT mice, C3aR-null mPFCGlu neurons display hyperexcitability upon LPS treatment, and enhanced excitation of mPFCGlu neurons is anti-depressant, suggesting a protective role of C3aR deficiency in these circumstances. In conclusion, C3aR modulates susceptibility to LPS-induced depressive-like behaviors through mPFCGlu neuronal excitability. This study identifies C3aR as a pivotal intersection of complement activation, mPFC dysfunction, and depression and a promising therapeutic target for MDD.
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Affiliation(s)
- Rui Sun
- Department of Neurology and Department of Psychiatry of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Research Center of System Medicine, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou, China; Biosensor National Special Laboratory, Key Laboratory for Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, China
| | - Meng-Yu Tang
- NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Center of Brain Science and Brain-machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
| | - Dan Yang
- Clinical Research Center, The second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yan-Yi Zhang
- NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Center of Brain Science and Brain-machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
| | - Yi-Heng Xu
- NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Center of Brain Science and Brain-machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
| | - Yong Qiao
- Department of Neurology and Department of Psychiatry of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Research Center of System Medicine, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou, China
| | - Bin Yu
- Key Laboratory of Novel Targets and Drug Study for Neural Repair of Zhejiang Province, School of Medicine, Hangzhou City University, Hangzhou, China
| | - Shu-Xia Cao
- Department of Neurology, Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hao Wang
- Affiliated Mental Health Center and Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui-Qian Huang
- Clinical Research Center, The second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong Zhang
- Department of Nuclear Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Ming Li
- NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Center of Brain Science and Brain-machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
| | - Hong Lian
- Department of Neurology and Department of Psychiatry of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Research Center of System Medicine, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of Novel Targets and Drug Study for Neural Repair of Zhejiang Province, School of Medicine, Hangzhou City University, Hangzhou, China.
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Xu F, Cheng P, Xu J, Wang X, Jiang Z, Zhu H, Fan H, Wang Q, Gao Q. Influencing factors of length of stay among repeatedly hospitalized patients with mood disorders: a longitudinal study in China. Ann Gen Psychiatry 2024; 23:15. [PMID: 38664741 PMCID: PMC11046813 DOI: 10.1186/s12991-024-00497-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/02/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Patients with mood disorders usually require repeated and prolonged hospitalization, resulting in a heavy burden on healthcare resources. This study aims to identify variables associated with length of stay(LOS) of repeatedly hospitalized patients with mood disorders and to provide information for optimizing psychiatry management and healthcare resource allocation. METHODS Electronic medical records (EMRs) of repeatedly hospitalized patients with mood disorders from January 2010 to December 2018 were collected and retrospectively analyzed. Chi-square and t-test were adopted to investigate the differences in characteristics between the two groups of short LOS and long LOS. Generalized estimating equation (GEE) was conducted to investigate potential factors influencing LOS. RESULTS A total of 2,009 repeatedly hospitalized patients with mood disorders were enrolled, of which 797 (39.7%) had a long LOS and 1,212 (60.3%) had a short LOS. Adverse effects of treatment, continuous clinical manifestation, chronic onset type, suicide attempt, comorbidity and use of antidepressants were positively associated with long LOS among all repeatedly hospitalized patients with mood disorders (P < 0.050). For patients with depression, factors associated with long LOS consisted of age, monthly income, adverse effects of treatment, continuous clinical manifestation, suicide attempt and comorbidity (P < 0.050). Whereas, for patients with bipolar disorder (BD), adverse effects of treatment, four or more hospitalizations and use of antidepressants contributed to the long LOS (P < 0.050). Influencing factors of LOS also vary among patients with different effectiveness of treatment. CONCLUSION The LOS in repeatedly hospitalized patients with mood disorders was influenced by multiple factors. There were discrepancies in the factors affecting LOS in patients with different diagnoses and effectiveness of treatment, and specific factors should be addressed when evaluating the LOS.
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Affiliation(s)
- Feng Xu
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmen Wai, Beijing, 100069, China
| | - Peixia Cheng
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmen Wai, Beijing, 100069, China
| | - Jiaying Xu
- Capital Medical University Affiliated Beijing Anding Hospital, Beijing, China
| | - Xiaonan Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmen Wai, Beijing, 100069, China
| | - Zhen Jiang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmen Wai, Beijing, 100069, China
| | - Huiping Zhu
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmen Wai, Beijing, 100069, China
| | - Hua Fan
- Capital Medical University Affiliated Beijing Anding Hospital, Beijing, China
| | - Qian Wang
- Capital Medical University Affiliated Beijing Anding Hospital, Beijing, China
| | - Qi Gao
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmen Wai, Beijing, 100069, China.
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Somelar-Duracz K, Jürgenson M, Viil J, Zharkovsky A, Jaako K. 'Unpredictable chronic mild stress does not exacerbate memory impairment or altered neuronal and glial plasticity in the hippocampus of middle-aged vitamin D deficient mice'. Eur J Neurosci 2024; 59:1696-1722. [PMID: 38269959 DOI: 10.1111/ejn.16256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/10/2023] [Accepted: 01/02/2024] [Indexed: 01/26/2024]
Abstract
Vitamin D deficiency is a worldwide health concern, especially in the elderly population. Much remains unknown about the relationship between vitamin D deficiency (VDD), stress-induced cognitive dysfunctions and depressive-like behaviour. In this study, 4-month-old male C57Bl/6J mice were fed with control or vitamin D free diet for 6 months, followed by unpredictable chronic stress (UCMS) for 8 weeks. VDD induced cognitive impairment and reduced grooming behaviour, but did not induce depressive-like behaviour. While UCMS in vitamin D sufficient mice induced expected depressive-like phenotype and impairments in the contextual fear memory, chronic stress did not manifest as an additional risk factor for memory impairments and depressive-like behaviour in VDD mice. In fact, UCMS restored self-care behaviour in VDD mice. At the histopathological level, VDD mice exhibited cell loss in the granule cell layer, reduced survival of newly generated cells, accompanied with an increased number of apoptotic cells and alterations in glial morphology in the hippocampus; however, these effects were not exacerbated by UCMS. Interestingly, UCMS reversed VDD induced loss of microglial cells. Moreover, tyrosine hydroxylase levels decreased in the striatum of VDD mice, but not in stressed VDD mice. These findings indicate that long-term VDD in adulthood impairs cognition but does not augment behavioural response to UCMS in middle-aged mice. While VDD caused cell loss and altered glial response in the DG of the hippocampus, these effects were not exacerbated by UCMS and could contribute to mechanisms regulating altered stress response.
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Affiliation(s)
- Kelli Somelar-Duracz
- Institute of Biomedicine and Translational Medicine, Department of Pharmacology, University of Tartu, Tartu, Estonia
| | - Monika Jürgenson
- Institute of Biomedicine and Translational Medicine, Department of Pharmacology, University of Tartu, Tartu, Estonia
| | - Janeli Viil
- Institute of Biomedicine and Translational Medicine, Department of Pharmacology, University of Tartu, Tartu, Estonia
| | - Alexander Zharkovsky
- Institute of Biomedicine and Translational Medicine, Department of Pharmacology, University of Tartu, Tartu, Estonia
| | - Külli Jaako
- Institute of Biomedicine and Translational Medicine, Department of Pharmacology, University of Tartu, Tartu, Estonia
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Zhao C, Chen Z, Lu X, Hu W, Yang R, Lu Q, Chen B, Huang C. Microglia-Dependent Reversal of Depression-Like Behaviors in Chronically Stressed Mice by Administration of a Specific Immuno-stimulant β-Glucan. Neurochem Res 2024; 49:519-531. [PMID: 37962706 DOI: 10.1007/s11064-023-04056-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
In recent years, the decline of microglia in the hippocampus has been shown to play a role in the development of depression, and its reversal shows marked antidepressant-like effects. β-glucan is a polysaccharide from Saccharomyces cerevisiae and has numerous beneficial effects on the nervous system, including improving axon regeneration and cognition. Considering its immuno-stimulatory activities in cultured microglia and brain tissues, we hypothesize that β-glucan may be a potential candidate to correct the functional deficiency of microglia and thereby alleviate depression-like behaviors in chronically stressed animals. An expected, our results showed that a single injection of β-glucan 5 h before behavioral tests at a dose of 10 or 20 mg/kg, but not at a dose of 5 mg/kg, reversed the depression-like behavior induced by chronic stress in mice in the tail suspension test, forced swimming test, and sucrose preference test. The effect of β-glucan (20 mg/kg) also showed time-dependent properties that were statistically significant 5 and 8, but not 3, hours after drug injection and persisted for at least 7 days. Fourteen days after β-glucan injection, no antidepressant-like effect was observed anymore. However, this effect was overcome by a second β-glucan injection (20 mg/kg) 14 days after the first β-glucan injection. Stimulation of microglia appeared to mediate the antidepressant-like effect of β-glucan, because both inhibition of microglia and their depletion prevented the antidepressant-like effect of β-glucan. Based on these effects of β-glucan, β-glucan administration could be developed as a new strategy for the treatment of depression.
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Affiliation(s)
- Cheng Zhao
- Department of Pharmacy, Affiliated Hospital of Nantong University, #20 Xisi Road, Nantong, 226001, Jiangsu, China.
| | - Zhuo Chen
- Invasive Technology Department, First People's Hospital of Nantong City, the Second Affiliated Hospital of Nantong University, #666 Shengli Road, Nantong, 226006, China
| | - Xu Lu
- Department of Pharmacology, School of Pharmacy, Nantong University, #19 Qixiu Road, Nantong, 226001, Jiangsu Province, China
| | - Wenfeng Hu
- Department of Pharmacy, Affiliated Maternal and Child Health Hospital of Nantong University, #399 Shijidadao, Nantong, 226007, China
| | - Rongrong Yang
- Department of Anesthesiology, Affiliated Hospital of Nantong University, #20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Qun Lu
- Department of Pharmacy, Nantong Third Hospital Affiliated to Nantong University, #60 Middle Qingnian Road, Nantong, 226006, Jiangsu, China
| | - Bingran Chen
- Department of Pharmacology, School of Pharmacy, Nantong University, #19 Qixiu Road, Nantong, 226001, Jiangsu Province, China
| | - Chao Huang
- Department of Pharmacology, School of Pharmacy, Nantong University, #19 Qixiu Road, Nantong, 226001, Jiangsu Province, China.
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Gusev E, Sarapultsev A. Interplay of G-proteins and Serotonin in the Neuroimmunoinflammatory Model of Chronic Stress and Depression: A Narrative Review. Curr Pharm Des 2024; 30:180-214. [PMID: 38151838 DOI: 10.2174/0113816128285578231218102020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/29/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION This narrative review addresses the clinical challenges in stress-related disorders such as depression, focusing on the interplay between neuron-specific and pro-inflammatory mechanisms at the cellular, cerebral, and systemic levels. OBJECTIVE We aim to elucidate the molecular mechanisms linking chronic psychological stress with low-grade neuroinflammation in key brain regions, particularly focusing on the roles of G proteins and serotonin (5-HT) receptors. METHODS This comprehensive review of the literature employs systematic, narrative, and scoping review methodologies, combined with systemic approaches to general pathology. It synthesizes current research on shared signaling pathways involved in stress responses and neuroinflammation, including calcium-dependent mechanisms, mitogen-activated protein kinases, and key transcription factors like NF-κB and p53. The review also focuses on the role of G protein-coupled neurotransmitter receptors (GPCRs) in immune and pro-inflammatory responses, with a detailed analysis of how 13 of 14 types of human 5-HT receptors contribute to depression and neuroinflammation. RESULTS The review reveals a complex interaction between neurotransmitter signals and immunoinflammatory responses in stress-related pathologies. It highlights the role of GPCRs and canonical inflammatory mediators in influencing both pathological and physiological processes in nervous tissue. CONCLUSION The proposed Neuroimmunoinflammatory Stress Model (NIIS Model) suggests that proinflammatory signaling pathways, mediated by metabotropic and ionotropic neurotransmitter receptors, are crucial for maintaining neuronal homeostasis. Chronic mental stress can disrupt this balance, leading to increased pro-inflammatory states in the brain and contributing to neuropsychiatric and psychosomatic disorders, including depression. This model integrates traditional theories on depression pathogenesis, offering a comprehensive understanding of the multifaceted nature of the condition.
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Affiliation(s)
- Evgenii Gusev
- Laboratory of Inflammation Immunology, Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, Ekaterinburg 620049, Russia
- Russian-Chinese Education and Research Center of System Pathology, South Ural State University, Chelyabinsk 454080, Russia
| | - Alexey Sarapultsev
- Russian-Chinese Education and Research Center of System Pathology, South Ural State University, Chelyabinsk 454080, Russia
- Laboratory of Immunopathophysiology, Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, Ekaterinburg 620049, Russia
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Morimoto K, Watanuki S, Eguchi R, Kitano T, Otsuguro KI. Short-term memory impairment following recovery from systemic inflammation induced by lipopolysaccharide in mice. Front Neurosci 2023; 17:1273039. [PMID: 37920299 PMCID: PMC10618367 DOI: 10.3389/fnins.2023.1273039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023] Open
Abstract
The relationship between neuroinflammation and mental disorders has been recognized and investigated for over 30 years. Diseases of systemic or peripheral inflammation, such as sepsis, peritonitis, and infection, are associated with increased risk of mental disorders with neuroinflammation. To elucidate the pathogenesis, systemic administration of lipopolysaccharide (LPS) in mice is often used. LPS-injected mice exhibit behavioral abnormalities with glial activation. However, these studies are unlikely to recapitulate the clinical pathophysiology of human patients, as most studies focus on the acute inflammatory response with systemic symptoms occurring within 24 h of LPS injection. In this study, we focus on the effects of LPS on behavioral abnormalities following recovery from systemic symptoms and investigate the mechanisms of pathogenesis. Several behavioral tests were performed in LPS-injected mice, and to assess neuroinflammation, the time course of the morphological change and expression of inflammatory factors in neurons, astrocytes, and microglia were investigated. At 7 days post-LPS injection, mice exhibited short-term memory impairment accompanied by the suppression of neuronal activity and increases in morphologically immature spines. Glial cells were transiently activated in the hippocampus concomitant with upregulation of the microglial phagocytosis marker CD68 3 days after injection. Here we show that transient glial cell activation in the acute response phase affects neuronal activity and behavior following recovery from systemic symptoms. These findings provide novel insights for studies using the LPS-induced inflammation model and that will contribute to the development of treatments for mental disorders of this etiology.
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Affiliation(s)
- Kohei Morimoto
- Laboratory of Pharmacology, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan
| | - Shu Watanuki
- Laboratory of Pharmacology, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan
| | - Ryota Eguchi
- Laboratory of Pharmacology, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan
| | - Taisuke Kitano
- Laboratory of Veterinary Biochemistry, School of Veterinary Medicine, Kitasato University, Aomori, Japan
| | - Ken-ichi Otsuguro
- Laboratory of Pharmacology, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan
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